The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 84, Issue 11

Scientific Article | November 01, 2002

Pulley Plasty Versus Resection of One Slip of the Flexor Digitorum Superficialis After Repair of Both Flexor Tendons in Zone II : A Biomechanical Study

P. J. Paillard, MD; P. C. Amadio, MD; C. Zhao, MD; M. E. Zobitz, MS; K. N. An, PhD

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Investigation performed at the Department of Orthopedics, Orthopedic Biomechanics Laboratory, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

P.J. Paillard, MD
P.C. Amadio, MD
C. Zhao, MD
M.E. Zobitz, MS
K.N. An, PhD
Department of Orthopedics, Orthopedic Biomechanics Laboratory, Mayo Clinic and Mayo Foundation, 200 First Street S.W., Rochester, MN 55905. E-mail address for P.C. Amadio: pamadio@mayo.edu

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the National Institutes of Health (National Institute of Arthritis and Musculoskeletal and Skin Diseases) grant AR44391 and a grant from the Mayo Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2002 Nov 01;84(11):2039-2045

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Abstract

Background: The outcome of repair of zone-II lacerations of the flexor digitorum superficialis and flexor digitorum profundus tendons remains suboptimal. We investigated the effects of two strategies to improve postoperative gliding in a human cadaveric hand.

Methods: The second, third, and fourth digits were harvested from ten fresh-frozen human cadaveric hands. Complete lacerations and repairs were made to the profundus and superficialis tendons at a location where both repair sites would pass beneath the A2 pulley with the proximal interphalangeal joint in 45&degree; of flexion. The gliding resistance of the flexor digitorum profundus tendon was measured following pulley plasty and following excision of one slip of the flexor digitorum superficialis. The breaking strength of the remaining slip of the flexor digitorum superficialis tendon was then measured.

Results: Pulley plasty and resection of one slip of the flexor digitorum superficialis tendon both significantly decreased gliding resistance compared with repair of both slips (p < 0.001). There was no difference in the mean gliding resistance between the pulley plasty and one-slip resection groups. The flexor digitorum superficialis slip was stronger after repair with a Becker suture (28.8 ± 9.0 N) than after repair with a modified Kessler (16.4 ± 4.5 N) or a zigzag suture (15.0 ± 5.7 N).

Conclusion: Both pulley plasty and resection of one slip of the flexor digitorum superficialis reduce gliding resistance after tendon repair in zone II of the hand.

Figures in this Article

Introduction

Introduction | Materials and Methods | Results | Discussion | References

For many hand surgeons, repair of flexor tendon injuries in zone II continues to present a clinical problem ^1-4 . Zone II, also called "no man's land," is the area between the proximal reflection of the synovial sheath, roughly at the level of the metacarpophalangeal joint, and the insertion of the flexor digitorum superficialis, at the midportion of the middle phalanx. In this area, the flexor digitorum superficialis and flexor digitorum profundus tendons glide within the tight confines of the fibro-osseous tendon sheath. The surgeon faces a dilemma because, if the finger is immobilized during healing, dense adhesions may bind the tendons within the sheath and limit motion. Conversely, uncontrolled early flexion may disrupt the tendon repairs. It is now well accepted that controlled motion increases tensile strength, reduces adhesion formation, and improves clinical results, but normal function remains an elusive goal ^1,5-7 . Tang and Shi ⁸ recommended subdividing zone II, from distal to proximal, into three smaller regions, IIa, IIb, and IIc. Although each zone is characterized by two tendons and a fibro-osseous sheath, the differential motion of the flexor digitorum superficialis and the flexor digitorum profundus tendons is greatest in zone IIc, and the clinical results are poorest in this zone.

Debate continues over the best treatment method to use when the flexor digitorum profundus and the flexor digitorum superficialis are both lacerated in the zone-IIc region. The subdivision IIc is the region covered by the A2 pulley ⁸ , and it contains the narrowest fibro-osseous gliding canal. One option to manage injuries in this area has been excision of the flexor digitorum superficialis tendon, which creates more space for the remaining flexor digitorum profundus tendon. However, excision of the whole superficialis tendon jeopardizes nutrition to the flexor digitorum profundus tendon, as the vinculum longum, which passes through the flexor digitorum superficialis decussation, provides the main vascular supply to the profundus tendon at this location ^v . Excision of the flexor digitorum superficialis insertion in the A2 pulley may also induce fibrosis. Therefore, the resection must be limited and not extended to the IIb subzone ⁸ , which extends from the proximal margin of the insertion of the flexor digitorum superficialis tendon to the distal margin of the A2 pulley. Additionally, resection of the flexor digitorum superficialis tendon, through the loss of its flexion action on the proximal interphalangeal joint, may also cause a swan-neck deformity ¹¹ or potentially reduce prehension power.

A more common treatment option is to repair both of the damaged tendons ^3,12,13 , although there is evidence that suturing both tendons in this constricted canal may impair tendon gliding ^8,14 . To overcome a constricted canal, a pulley plasty ^v has been described, but clinical or biomechanical results have not been addressed in the literature. Finally, there is the option of resecting one slip of the flexor digitorum superficialis and repairing the other as a way to reduce the volume of the contents within the tendon sheath ^18-20 . However, little data are available ²¹ to conclude whether the strength of one repaired flexor digitorum superficialis slip is sufficient to support the loads applied by rehabilitative regimens involving early motion.

The purpose of this study was to investigate the biomechanical effects of excision of one slip of the flexor digitorum superficialis tendon and to compare the results with those after repair of both slips and after pulley plasty. With use of a human cadaveric model, we measured the gliding resistance of the flexor digitorum profundus following repair of the flexor digitorum profundus and flexor digitorum superficialis tendons and then measured the breaking strength of various repairs on the remaining slip of the flexor digitorum superficialis tendon. Our hypothesis was that excision of one slip of the flexor digitorum superficialis would improve the gliding of the repaired tendons while preserving sufficient strength to support the requirements of early mobilization.

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Figs. 1-A through 1-E:: Figs. 1-A through 1-E Diagrams showing the modified Kessler suture (Fig. 1-A), Becker suture (Fig. 1-B), and zigzag suture (Figs. 1-C, 1-D, and 1-E). (Reprinted, with permission, from Paillard PJ, Amadio PC, Zhao CF, Zobitz ME, An KN. Gliding resistance after FDP and FDS tendon repair in zone II. Acta Orthop Scand. 2002;73:466-7.)

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Fig. 2:: The gliding resistance device. 1 = motor, 2 = tensile load transducer, 3 = flexor digitorum superficialis, 4 = flexor digitorum profundus, 5 = saline solution bath, 6 = custom jig, and 7 = weight. Fp = proximal part of the flexor digitorum profundus tendon attached to a force transducer, and Fd = distal end of the flexor digitorum profundus tendon attached to a force transducer. (Reprinted, with permission, from Paillard PJ, Amadio PC, Zhao CF, Zobitz ME, An KN. Gliding resistance after FDP and FDS tendon repair in zone II. Acta Orthop Scand. 2002;73:467.)

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Fig. 3:: Pulley plasty, as described by Kapandji ¹⁵ . (Reproduced, with modification, from: Kapandji IA. [Reconstructive augmentation of the metacarpal tendons.] Ann Chir Main. 1983;2:281-2. French. Reprinted with permission.)

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Figs. 4-A and 4-B:: Figs. 4-A and 4-B The mean (Fig. 4-A) and maximum (Fig. 4-B) gliding resistance after the excision of one slip of the flexor digitorum superficialis and after the pulley plasty. FDP = flexor digitorum profundus, and FDS = flexor digitorum superficialis.

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Fig. 5:: Maximum force to failure for the three repair methods of the flexor digitorum superficialis (one slip).

Materials and Methods

Introduction | Materials and Methods | Results | Discussion | References

Ten fresh-frozen cadaveric human hands were used in this in vitro study. The specimens were from three females and seven males with a mean age of seventy-nine years (range, thirty-nine to ninety-five years) at the time of death. Five right and five left hands were used.

The second, third, and fourth digits of each hand were carefully dissected through Bruner ²² incisions. The entire digit tendon system was exposed, leaving the sheath intact. An incision was made in the tendon sheath between the A2 and A3 pulleys. With the finger in full extension, a mark was made on both the flexor digitorum profundus and flexor digitorum superficialis tendons at the level of the distal edge of the A2 pulley. The finger was then moved to full flexion through traction on the flexor tendons, and second marks were made on the flexor digitorum profundus and flexor digitorum superficialis tendons at the distal edge of the A2 pulley. Tendon excursion from full extension to full flexion was considered to be the distance between these two marks on each tendon.

With the proximal interphalangeal joint in 45&degree; of flexion and the distal interphalangeal joint in full extension, a complete laceration of both tendons of the digit was created at the distal edge of the A2 pulley. This is a common site of tendon injury resulting from grasping a sharp object. Repair of the tendons would then represent the "worst-case scenario" in regard to tendon gliding, as both tendons would simultaneously pass beneath the A2 pulley during flexion.

After the tendons were lacerated, the proximal phalanx, the proximal portion of the middle phalanx, the flexor digitorum profundus and flexor digitorum superficialis tendons, and the A2 pulley were dissected free. The flexor digitorum profundus tendon was repaired with a modified Kessler repair with use of 3-0 Surgilon suture (United States Surgical and Davis and Geck, Norwalk, Connecticut), and a running circumferential suture of 6-0 Prolene (Ethicon, Somerville, New Jersey). Three different suture techniques for repair of the flexor digitorum superficialis were studied in ten digits each ( Figs. 1-A through 1-E ): the modified Kessler repair with use of 4-0 Ticron (United States Surgical and Davis and Geck); the Becker repair with use of 4-0 Ticron; and a new zigzag running suture technique with use of 6-0 nylon. The zigzag running suture was made on the anterior face of the flexor digitorum superficialis slip with a 30&degree; inclination between the tendon axis and the outside stitch. The knot was placed inside the laceration, and three loops were placed on each end of each of the two slips of the flexor digitorum superficialis.

Gliding resistance was measured with use of a previously described technique 23 ( Fig. 2 ). In the testing model, the flexor digitorum profundus tendon was actively moved, at a rate of 2.0 mm/sec, over the stationary flexor digitorum superficialis tendon and the A2 pulley. Tension (2.0 N) was applied to the proximal part of the flexor digitorum superficialis tendon while the distal end remained attached to the middle phalanx. The proximal part of the flexor digitorum profundus tendon was attached to a custom-made force transducer (Fp) and then to a mechanical actuator with a linear potentiometer. The distal end of the flexor digitorum profundus tendon was also connected to a force transducer (Fd) and then to a 4.9-N weight. On the basis of previous experience ²⁴ , we determined that fixed angles between the horizontal plane and the proximal (30&degree;) and distal (20&degree;) cables were sufficient to measure gliding resistance. Throughout testing, the specimen was immersed in a saline solution bath.

The tendons were first tested in the intact condition and once again after repair of the flexor digitorum profundus and flexor digitorum superficialis tendons. Then the digits were equally divided into two groups. In the first set of fifteen digits, the ulnar slip of the flexor digitorum superficialis tendon was resected. In the other set of fifteen, a pulley plasty by flap transposition advancement, as described by Kapandji, was performed and repaired with a running suture ¹⁵ ( Fig. 3 ). The gliding resistance was then measured again, with use of the same testing configuration. The length of the pulley before and after the pulley plasty was also measured.

Gliding resistance was calculated as the force differential between the proximal (Fp) and distal (Fd) force transducers for one flexion-extension cycle. Since the distal force (Fd) remained constant (4.9 N), the composite gliding resistance for flexion and extension motion was 0.5 × (Fp flexion - Fp extension). The results of gliding resistance were summarized as the mean and maximum gliding resistances. For each tendon, the results were expressed as the percent increase from the measurement made on the intact tendon.

After gliding resistance had been measured, the breaking strength of the repaired flexor digitorum superficialis tendons with one slip was measured. Since the tendons that had been assigned to the pulley plasty contained two slips of the flexor digitorum superficialis, the ulnar slip was excised prior to measurement. Thus, for each of the suture repairs (modified Kessler, Becker, and zigzag), there was breaking strength data on ten flexor digitorum superficialis tendons. The tendons were loaded to failure in a servohydraulic testing machine (MTS, Minneapolis, Minnesota) at a rate of 0.33 mm/sec.

For simplicity of analysis, all fingers were assumed to be independent. The results were expressed as the mean and the standard deviation unless otherwise noted. The effects of the type of superficialis tendon repair (modified Kessler, Becker, or zigzag) and the strategy for the reduction of gliding resistance (resection of one superficialis slip or pulley plasty) were assessed with use of a two-factor analysis of variance model. No interactions were identified among the three superficialis repairs and the two strategies for reducing gliding resistance. Furthermore, for each of the strategies to reduce gliding resistance, the change between the intact tendon and the result after treatment was evaluated with use of a two-factor analysis of variance model (the main factors of superficialis repair and timing) with repeated measures on one factor. No significant interactions between the main effects were detected. In both analyses, the measures of the mean and the maximum gliding resistance were evaluated. The maximum force to failure among the three superficialis repair types was analyzed with use of a one-way analysis of variance. All statistical tests were two-sided with the threshold of significance set at a = 0.05. The analysis was completed with use of SAS software (version 6.12; SAS Institute, Cary, North Carolina).

Results

Introduction | Materials and Methods | Results | Discussion | References

The intact flexor digitorum profundus tendons had an overall mean gliding resistance of 0.40 ± 0.13 N and an overall maximum gliding resistance of 0.63 ± 0.30 N. Following repairs to the flexor digitorum profundus and flexor digitorum superficialis tendons, the mean gliding resistance significantly increased (p < 0.001) by nearly 238% compared with the intact state. Since no significant interaction was detected with respect to either the mean (p = 0.69) or the maximum (p = 0.69) gliding resistance among the three flexor digitorum superficialis repair techniques, the gliding resistance results for the three repair techniques were combined in the analysis.

After excision of one slip of the flexor digitorum superficialis tendon, the mean and maximum gliding resistances significantly decreased by 42% ± 11% (p < 0.001) and 41% ± 29% (p < 0.001), respectively, compared with repair of both slips. Following the pulley plasty, the mean and maximum gliding resistances also significantly decreased by 35% ± 21% (p < 0.001) and 21% ± 29% (p = 0.02), respectively, compared with repair of both slips ( Figs. 4-A and 4-B ). A comparison of the excision of one slip of the flexor digitorum superficialis and the pulley plasty revealed no significant difference in the mean gliding resistance (0.77 N versus 0.78 N, respectively), but a significant difference (p = 0.007) was demonstrated in the maximum gliding resistance (1.2 N for excision versus 1.6 N for pulley plasty).

The pulley length decreased by an average of 43% (range, 29% to 58%) after the pulley plasty.

A comparison of the gliding resistance among the three different repairs of the flexor digitorum superficialis demonstrated a significantly higher gliding resistance with the modified Kessler suture than with the Becker and zigzag repairs (p = 0.001).

The maximum force to failure of the Becker suture (28.8 ± 9.0 N) was significantly greater than that of the modified Kessler (16.4 ± 4.5 N) and zigzag (15.0 ± 5.7 N) repair techniques (p < 0.001) ( Fig. 5 ).

Discussion

Introduction | Materials and Methods | Results | Discussion | References

It is generally accepted that postoperative motion can reduce adhesion formation following tendon repair. The ease of motion and the amount of tendon loading required to induce motion are, in turn, governed by the resistance to tendon motion. A high gliding resistance can impede motion or require a tendon force to induce motion, which may jeopardize the integrity of the tendon repair. There is also evidence that motion associated with high resistance, even if the tendon repair remains intact, can induce abrasion of the tendon surface ²⁵ . Thus, gliding resistance after flexor tendon repair is an important factor that could influence the outcome of the surgery, especially in zone II, where two flexor tendons reside within the tendon sheath. Although gliding resistance between the flexor digitorum profundus tendon and the A2 pulley has been studied ²⁶ , the gliding characteristics after injury and repair to both tendons are unknown.

The results of this study demonstrated that repair of the flexor digitorum superficialis tendon increases the gliding resistance during motion of the flexor digitorum profundus tendon. The results also demonstrated that both pulley plasty and resection of one flexor digitorum superficialis slip can substantially decrease gliding resistance when both tendons are repaired. We do not believe, however, that the two options are equally useful clinically. The pulley plasty, in addition to adding a laceration and suture line in the pulley where none had existed, effectively shortens the length of the pulley. Thus, although the laceration and repair site on the flexor digitorum superficialis tendon was located beneath the pulley prior to the pulley plasty, afterward it was located distal to the pulley edge. The pulley plasty, therefore, would seem to have little advantage over simple resection of the distal pulley edge; indeed, the resection would have the advantage of preserving a normal remaining pulley segment, with no suture line in the pulley itself to serve as a weak point or a potential nidus for adhesions. If one were to consider the option of addressing the pulley as a means of reducing friction, we would prefer simple pulley shortening, as has been advocated by some authors ²⁷ , rather than pulley plasty. The effect of combining pulley shortening with excision of the flexor digitorum superficialis could be the focus of a future study.

With excision of one slip of the flexor digitorum superficialis tendon, the repair sites of the flexor digitorum profundus and flexor digitorum superficialis tendons were both still located within the pulley, but the total tendon bulk was less. It is also important to consider the strength of the remaining flexor digitorum superficialis slip and whether it is sufficient to withstand the loading necessary to overcome gliding resistance and therefore permit tendon motion.

A comparison of the gliding resistance among the three repairs of the flexor digitorum superficialis tendon with one slip resected showed no significant difference. However, the strength of the Becker repair was significantly greater than that of the other two repair types. In an in vivo study on flexor tendon forces ²⁸ , a force of 2 N was measured on the flexor digitorum superficialis during passive motion and a force of 17 N was measured during active pinch of the index finger. Even with a potential decrease in tendon repair strength to one-third of its initial value during healing ²⁹ , a repair strength of 28 N for a Becker repair of the single slip of the flexor digitorum superficialis tendon would seem sufficient to allow passive mobilization.

Since this was an in vitro study, we could not evaluate any positive or negative effects of our manipulations, whether of the repair type or the pulley plasty, on aspects of tendon healing, such as adhesion formation, in vivo repair strength, or restoration of the gliding surface. We speculated that resection of one flexor digitorum superficialis slip after laceration of both tendons would provide fewer sutures and less bulk and the reduced gliding resistance would facilitate greater motion, which could reduce adhesion formation, thereby improving the clinical results.

Another limitation to our methodology was that the flexor digitorum superficialis tendon remained stationary during testing of the gliding resistance. During normal flexion, the flexor digitorum superficialis and flexor digitorum profundus tendons move relative to each other. Ideally, for a gliding resistance test of both tendons, mechanical actuators should pull each tendon at different rates. Although our method is a simplification of this ideal, the scenario that we tested would produce the highest gliding resistance, as we positioned the repair sites to be at the same location beneath the A2 pulley. Therefore, we believe that comparisons of the pulley plasty and the resection of one flexor digitorum superficialis tendon slip reflect the relative differences that would be reasonably expected to occur in vivo.

We believe that the gliding resistance following the repair of tendon lacerations contributes to the quality of the outcome, and some preliminary data have suggested that this is indeed the case ³⁰ . Resection of one slip of a lacerated flexor digitorum superficialis tendon, combined with the lower friction, higher strength Becker repair of the remaining flexor digitorum superficialis slip, could be a new solution for managing simultaneous lacerations of the flexor digitorum superficialis and flexor digitorum profundus tendon in zone IIc. However, before a clinical recommendation can be made, the results must be confirmed by an in vivo study.

References

Introduction | Materials and Methods | Results | Discussion | References

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Topics

lacerations ; sutures ; tendon ; tendon repair ; flexor tendon ; flexor digitorum superficialis muscle of hand ; tendon of flexor digitorum profundus

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P. J. Paillard, P. C. Amadio, C. Zhao, M. E. Zobitz, K. N. An; Pulley Plasty Versus Resection of One Slip of the Flexor Digitorum Superficialis After Repair of Both Flexor Tendons in Zone II A Biomechanical Study. The Journal of Bone & Joint Surgery. 2002 Nov;84(11):2039-2045.

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